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Geriatric Malnutrition
Richard Allan Bettis, Fourth-Year Pharm.D. Candidate
Preceptor: Dr. Ali Rahimi
University of Georgia College of Pharmacy
Background

A frequent and common condition
in the elderly associated with:
Increased morbidity
Increased mortality
Increased hospitalizations
Reduced quality of life
Frequency
Occurs in 5-10% of older patients residing
in nursing homes or long-term care
facilities
 Occurs in up to 50% of older patients
when discharged from the hospital
 Most reversible or treatable causes of
undernutrition are frequently overlooked
by physicians

Background

Undernutrition or malnutrition can be
a result of two likely scenarios:
Protein energy wasting characterized
primarily by weight loss
Individual nutrient deficiencies
characterized by a lack of single
nutrients and seen more commonly in
older persons
The Body & Energy

Total energy expenditure based upon an
individual’s basal metabolic rate (or BMR)
Energy required for physical activity and
creating fuel reserves after feeding
Dependent upon age, weight, gender, and
activity level
Energy & Aging

BMR decreases with age regardless of
constant body weight
Result of muscle tissue replacement by less
metabolically active adipose tissue
Energy & Nutrients

Protein, carbohydrates, and fat account
for a percentage of total calories to meet
nutritional needs
Energy & Nutrients

Energy yield varies between different
types of foods
Energy & Proteins

More energy from protein is highly
encouraged and supported
The Body & Energy
Metabolic fuels in excess of energy
expenditure results in obesity
 A lack of metabolic fuel to supply
energy expenditure results in
emaciation, wasting, marasmus,
kwashiorkor
 Both situations are associated with
increased mortality

Nutrient Deficiency
A lack of single
nutrients resulting
in less common
disease states
 Very rarely seen in
developed
countries except
occasionally in
older persons

Weight Loss & Mortality

When older patients lose weight they
have a doubling in their risks for death
Even if the patient is overweight!

Weight loss increases likelihood of:
Hip fractures
Institutionalization
Downward spiral of negative events

Weight loss is the best sign of treatable
undernutrition
Caregiver Perceptions

Weight loss is
the best sign of
treatable
undernutrition
or malnutrition
Nutritional Status


There is no
gold standard
for diagnosis
of malnutrition
There are
several quick
assessment
tools
Nutritional Assessment Tools

Mini-Nutritional
Assessment (MNA)
Most established
screening tool for
older adults
Difficult to distinguish
between patients at
risk for malnutrition
and frailty
Not applicable if
patients are noncommunicable
Nutritional Assessment Tools

Simplified Nutritional Assessment
Questionnaire (SNAQ)
High sensitivity and specificty to detect
weight loss over next 6 months

Malnutrition Universal Screening
Tool (MUST)
Uses BMI, weight loss, and an acute
disease effect score
Predictor of mortality and length of stay
in hospital
Simplified
Nutritional
Assessment
Questionnaire
(SNAQ)
Nutritional Assessment Tools

Nutritional Risk Screening (NRS)
Proposed universal screening tool for
malnutrition in hospitalized patients
Assesses BMI, weight loss, appetite, and
severity of disease
Applicable to more types of patients
Nutritional Markers

Serum protein assays
Albumin, prealbumins, retinol binding proteins
Not specific to detect malnutrition or changes
in nutritional status
Reductions in these proteins are better
indicators of illness
Nitrogen Balance

Normally at equilibrium
Intake = output
No change in total body
content of protein

Positive nitrogen balance
Growing children, pregnancy,
recovery from protein loss
Excretion of nitrogenous
compounds is less than intake
Net retention of nitrogen is in
the body as protein
Nitrogen Balance

Nitrogen balance studies show consuming
more than 14% of energy source from
protein is more than enough to increase
muscle protein synthesis
Amino Acids

Essential
Cannot be synthesized in the body
If any of these are lacking, then nitrogen
balance will not be possible
Histidine, isoleucine, leucine, lysine,
methionine, phenylalanine, threonine,
tryptophan, and valine

Non-essential
Can be synthesized from the body or from
essential amino acids
Not necessary for nitrogen balance
Weight Loss Complications
Severe weight loss
leads to protein
malnutrition and a
downward spiral of
adverse effects
 Loss of weight also
leads to loss of:

Fat
Muscle
Bone
Albumin
Weight Loss Cause

A lack of metabolic fuel to supply
energy expenditure results in weight
loss, emaciation, and wasting
Weight Loss Causes

Six major causes of weight loss
in older patients:
Anorexia
Cachexia
The
Sarcopenia
“Triple Threat”
Malabsorption
Hypermetabolism
Dehydration
“Anorexia of Aging”
Anorexia is an independent predictor
of mortality
 Reduction in food intake as
individual’s age

Males – 30%
Females – 20%

Causes of anorexia in older patients
are multifactorial
Physiological
Psychological
Drug or disease induced
“Anorexia of Aging”
Causes of anorexia
in older patients are
multifactorial
 Physiological
 Psychological

 Depressed or cognitively
impaired patients

Disease or drug
induced
 Decreased appetite due
to acute disease or
medication effects
“Anorexia of Aging”

Physiological changes
Decrease in taste and olfaction resulting
in decreased enjoyment of food
Decrease in gastric emptying resulting in
early satiation signals
Changes in gut hormones involved in
(satiety or feelings of fullness)
Gut Hormones
“Anorexia of Aging”

Gut hormone changes and
contribution to anorexia
Increase in cholecystokinin (CKK) release
and sensitivity resulting in greater
satiating effects
Increase in leptin levels resulting in
increased satiety after meals
Reduced sensitivity to ghrelin associated
with reductions in hunger sensation
“Anorexia of Aging”
Anorexia is
multifactoral
Causes of Weight Loss

Six major causes of weight loss in elderly:
Anorexia
Cachexia
The
Sarcopenia
“Triple
Threat”
Malabsorption
Hypermetabolism
Dehydration
Cachexia
Severe wasting disorder characterized by loss
of both fat and muscle
 Caused by effects from the overproduction of
pro-inflammatory cytokines resulting from a
variety of illnesses
 Marked by changes in other markers:

Increases C-reactive protein
Decreases serum albumin
Causes anemia
Cytokine Overproduction
Usually overlapped with anorexia and
sarcopenia in older individuals
 Increases resting metabolic rate
resulting in higher metabolic demands
 Decreases both gastric emptying and
intestinal motility

Causes of Weight Loss

Six major causes of weight loss
in older patients:
Anorexia
Cachexia
The
Sarcopenia
“Triple Threat”
Malabsorption
Hypermetabolism
Dehydration
In Greek,
translates
literally to
“poverty of flesh”
 Characterized by
muscle atrophy
and a loss of
muscle
functionality
 Associated with
aging and
prevented by
exercise

Sarcopenia
The “Triple Threat”
Causes of Weight Loss

Six major causes of weight loss
in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
Malabsorption



Most commonly caused by celiac disease and
pancreatic insufficiency in older patients
Serum levels of vitamin A and beta-carotene used
to diagnose fat malabsorption
Screenings for various immunoglobins and
antibodies used to diagnose celiac disease
Causes of Weight Loss

Six major causes of weight loss
in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
Hypermetabolism
When energy demand
exceeds nutrient intake
 Most commonly caused by
hyperthyroidism and
pheochromocytoma in older
patients

Hypermetabolism

Apathetic hyperthyroidism
Weight loss
Atrial fibrillation
Proximal muscle weakness
Blepharoptosis (not exophthalmos)

Pheochromocytoma
Adrenal gland tumor
Consider if hypertensive and losing weight
Causes of Weight Loss

Six major causes of
weight loss in older
patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
Dehydration
Reduced total body water
 Normal daily fluid requirement is
30ml/kg body mass

“Anorexia of Aging”

Causes of anorexia in older patients
are multifactorial
Physiological
Psychological
Drug or disease induced
“Anorexia of Aging”

Psychological manifestations
Reactive depression
Change in living conditions
Food refusal behaviors

All are not uncommon and can lead
to weight loss and malnutrition
Depression
Most common cause of treatable anorexia
in community and institutional settings
 Late-life depression is significantly
underdiagnosed in older persons
 Corticotropin-releasing hormone (an
anorexogenic) is elevated in patients with
depression

Relocation
Change in living conditions evokes
psychological anorexic responses
 Late-onset paranoia

Fear of poisoning

Indirect self-destructive behavior (ISDB)
An unconscious method of suicide
May be due to trauma of relocation
Food Refusal Behaviors
Most prevalent in cognitively impaired
 Common in demented elderly patients due
to agnosia or dyspraxia

Difficulty interpreting sensory data and
not recognizing an object as food
Difficulty with motor movements and
unable to open mouth despite intentions to

Common refusal behaviors in intermediatestage Alzheimer’s patients would be:
Distraction from eating
Verbal refusal to eat
Food Refusal Behaviors

Deliberate refusal
Indirect self-destructive behavior (ISDB)
Reflexive withdrawal behavior
 Dislike of a certain food
 Protest against certain caregiver
 It is crucial to distinguish between
refusal to eat and lack of ability to eat

Patients with dysphagia may refuse food
Indirect self-destructive behavior (ISDB)
‘‘The grandfather, 81, one day removed his false teeth and
announced that he was no longer going to eat or drink.
Three weeks later, to the day, he died.”
Management Nutrition
Refusals
Energy Wasting
& Weight Loss

The basics:
Provide adequate
food supplementation

Early on:
Food variety
High calorie food
Calorie supplements

Focus on:
Diagnosing causes
Treating treatable
causes
“Anorexia of Aging”

Common causes of pathological and
treatable anorexia in the elderly:
Depression
Medications
Therapeutic diets
Cancer
Uncontrolled pain
Treatable Causes
Management
Calorie supplementation decreases
mortality and hospital lengths of stay
 Cachexia shown to be responsive to protein
calorie supplementation

Increase in 6-minute walks
Decreased hospitalizations
When?
Oral calorie supplements between meals
 Avoid supplementing calories during meals

Reduction in food intake
No net increase in total caloric ingestion
How?

Environmental considerations
Improve food taste
Avoid therapeutic diets with limited justification
Allow extra time to eat during mealtimes
Spend time feeding impaired patients
Other aesthetic considerations

Behavioral modifications
Improve quality of relationships between
patient and feeder
Use touch or verbal cueing
What Else?

Orexigenic medications available to
stimulate appetite
Megestrol acetate
Dronabinol
Testosterone
Megestrol Acetate

Orexigenic agent with mechanisms to
increase food intake and cause weight gain
Progestational agent
Corticosteroid activity
Mild testosterone-like activity
More effective in women than men
Reduces cytokine activity
Megestrol Acetate

Side effects
Deep vein thrombosis
Severe constipation in older patients
Fluid retention
Not recommended for sedentary patients
Not recommended for use >3 months at one time
Synergistic effects when combined with
olanzapine
Dronabinol
Orexigenic agent and extract of
tetrahydrocannabinol (THC) with
mechanisms to produce small increases in
appetite and weight gain
 Used in palliative care settings:

Reduces nausea
Increases enjoyment of both food and life
Other Agents

Testosterone
Produces weight gain
Decreases hospitalizations in frail older patients
Used in combination with caloric supplementation

Agents with roles in cachexia treatment
Low dose steriods (5mg prednisone daily)
Selective androgen receptor modulators
(ostarine)
Activin IIR decoy antibodies
Myostatin antibodies
Medications

Medications can cause weight loss by:
Affecting food intake
Diminishing appetite
Causing nausea, vomiting, or GI irritation
Altering taste and smell
Induce depression

Should consider using a minimum effective
dose or discontinuing medications opposing
weight gain or caloric supplementation
Medications

Some medications may cause anorexia
Theophylline
Digoxin
Neuroleptics
SSRIs
Nutritional Rehabilitation

Specialized nutrition regarded
as a last resort
Parenteral feeding
Enteral feeding

Overused in the U.S. especially
in patients with dementia
No evidence of a reduction in
mortality or improvements of
quality of life
Specialized Nutrition
Only small fraction of malnourished
patients will benefit from specialized
nutritional support (or SNS)
 In elderly or chronically ill patients the
decision to specialty feed is based upon
whether or not quality of life will be
extended
 Multiple considerations before decision
to implement SNS

Algorithm
Will quality
of life be
extended?
Specialized Nutrition

Enteral or “tube feeding”
Tube placed into the gut to deliver liquid
formulations which contain all essential nutrients

Parenteral or “intravenous feeding”
Infusion of nutrient solutions directly into the
bloodstream via peripherally located or centrally
located vein
Both associated with risk and discomfort
 Both difficult to stop once started

Specialized Nutrition Risk

Safest route is to avoid SNS



Closely monitor and ensure adequate oral food intake
Adding oral liquid supplement
Using an appetite stimulant in eligible patients
Enteral Feeding

Preferred route – “If the gut works, then use it”
Maintains gut functionality
Less risk for infection
Intestinal tolerance limited by
gastric retention or diarrhea
 Often required in patients with:

Anorexia
Impaired swallowing or dysphagia
Bowel disease
Parenteral Feeding

Less preferred route
Greater risk for infection
Higher chance of inducing hyperglycemia

Often required in patients with:
Prolonged ileus or obstruction
Severe hemorrhagic pancreatitis
Electrolytes & Specific Nutrients
Trace Metals
Ethics & Controversy

Food refusals
Distinguishing between competent and
demented patients
Identifying reversible symptoms such as
unmanaged pain or depression
Caregiver decision to force feed patients
Ethics & Legality

Enteral and parenteral feeds
Ordinary care or other medical treatment?
A patient has the right to refuse?
Supportive care while starving?
Management

Undernutrition or malnutrition can be
a result of two likely scenarios:
Individual nutrient deficiencies
characterized by a lack of single
nutrients and seen more commonly in
older persons
Protein energy wasting characterized
primarily by weight loss
Nutrient Deficiencies

The basics:
Replace the target nutrient
Prevention is key

Important deficiencies in older patients:
Vitamin D
Iron
Folate
B-12
Zinc
Vitamin D Deficiency
Associated with fractures, muscle loss,
falls, and increased mortality
 25-hydroxy vitamin D levels are gradually
reduced as part of the aging process

Levels are <30ng/mL in many older patients

Replacement of 800-1000 IU daily is
appropriate for most older patients
Iron Deficiency

Most commonly associated with iron
deficient anemia
Characterized by low iron and ferritin levels

Once daily oral replacement for 6 weeks
is appropriate for most older patients
Reticulocyte count after 1 week of therapy
Parenteral products may be necessary if no
increase in reticulocytes (likely due to
malabsorption)
Folate & B12 Deficiencies

Most commonly associated with
Both deficiencies characterized by elevated
homocysteine levels
Methymalonic acid specific for B12 deficiency

Oral or injectable replacement is
appropriate for most older patients
Vitamin B12 1000 IU orally every day or
1000IU weekly injections x 4weeks
Zinc Deficiency

Most commonly associated with:
Diabetics
Cancer patients
Individuals receiving diuretics

Role of replacement is uncertain
Recommended Intakes
Vitamin D Supplementation
Thank you !
REFERENCES
1.
2.
3.
4.
5.
Adams NE, Bowie AJ, et al. Recognition by medical and nursing
professionals of malnutrition and risk of malnutrition in elderly
hospitalised patients. Nutrition & Dietetics. 2008; 65: 144-150. DOI:
10.1111/j.1747-0080.2008.00226.x
Bender DA, Mayes PA. Chapter 43. Nutrition, Digestion, & Absorption. In:
Murray RK, Kennelly PJ, Rodwell VW, Botham KM, Bender DA, Weil PA, eds.
Harper's Illustrated Biochemistry. 29th ed. New York: McGraw-Hill; 2011.
http://www.accesspharmacy.com/content.aspx?aID=55885448. Accessed
February 6, 2013.
Bender DA. Chapter 44. Micronutrients: Vitamins & Minerals. In: Murray
RK, Kennelly PJ, Rodwell VW, Botham KM, Bender DA, Weil PA, eds.
Harper's Illustrated Biochemistry. 29th ed. New York: McGraw-Hill; 2011.
http://www.accesspharmacy.com/content.aspx?aID=55885518. Accessed
February 6, 2013
Benelem B. Satiety and the anorexia of ageing. British Journal of
Community Nursing. 2009; 14 (8): 332-335.
Berry EM, Marcus EL. Disorders of Eating in the Elderly. Journal of Adult
Development. 2000; 7 (2): 87-96.
REFERENCES
6.
7.
8.
9.
10.
Bistrian BR, Driscoll DF. Chapter 76. Enteral and Parenteral Nutrition
Therapy. In: Fauci AS, Kasper DL, Jameson JL, Longo DL, Hauser SL,
eds. Harrison's Principles of Internal Medicine. 18th ed. New York:
McGraw-Hill; 2012.
http://www.accesspharmacy.com/content.aspx?aID=9100156. Accessed
February 8, 2013.
Drescher T, Singler K, et al. Comparison of two malnutrition risk screening
methods (MNA and NRS 2002) and their association with markers of
protein malnutrition in geriatric hospitalized patients. European Journal of
Clinical Nutrition. 2010; 64: 887-893.
Karen L. Nestle Nutrition Insitute. The Elderly: Nutritional Needs,
Challenges, Screening, and Solutions. May 2012 Webinar.
http://www.nestle-nutrition.com/nirf/cm2/upload/C2F33D34-93164155-9F0F-58FDD9E638D9/HANDOUTS-Nestle-Webinar-052412-SlidesFor-Recording.pdf
Morley JE. Undernutrition in older adults. Family Practice. 2012; 29: i89i93. Doi: 10.1093/fampra/cmr054.
National Academy of Sciences. Institute of Medicine. Food and Nutrition
Board. Dietary Reference Intakes: Recommended Intakes for Individuals
http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/
Activity%20Files/Nutrition/DRIs/5_Summary%20Table%20Tables%2014.pdf